A nurse is conducting a class on Breast Self-Examination (BSE) for women of childbearing age. The nurse should include which of these statements that indicates the proper BSE technique?

The best time to perform BSE is immediately prior to the menstrual cycle

If pregnancy is suspected, BSE should not be performed until post delivery

The best time to perform BSE is 4 to 7 days after the first day of the menstrual period

The woman with diagnosed fibrocystic breast tissue should not rely on BSE

Answer and Explanation

The Correct Answer is C

A) The best time to perform BSE is immediately prior to the menstrual cycle:
Performing a breast self-examination (BSE) immediately prior to the menstrual cycle is not ideal because hormonal changes leading up to menstruation can cause the breasts to become swollen, tender, and lumpy. These changes could make it difficult to detect subtle lumps or changes in the breast tissue. For the most accurate assessment, it's recommended that women avoid performing BSE during the premenstrual phase when the breast tissue is most likely to be affected by hormonal fluctuations.

B) If pregnancy is suspected, BSE should not be performed until post-delivery:
This statement is incorrect. There is no contraindication to performing a breast self-examination during pregnancy, and it is important for pregnant women to continue self-monitoring for any changes in breast tissue. In fact, BSE should be performed regularly during pregnancy, as the breast tissue can undergo changes due to hormonal shifts, and early detection of any abnormalities is key to successful management.

C) The best time to perform BSE is 4 to 7 days after the first day of the menstrual period:
This is the correct recommendation. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period because the breasts are least likely to be swollen or tender during this time. Hormonal levels are more stable at this point in the menstrual cycle, and any lumps or changes in the tissue are more likely to be noticeable. Performing BSE during this time increases the likelihood of detecting potential abnormalities.

D) The woman with diagnosed fibrocystic breast tissue should not rely on BSE:
While it is true that women with fibrocystic breast changes may experience lumpy, tender tissue, they should still perform BSE regularly. Fibrocystic tissue can sometimes make it more difficult to distinguish between normal and abnormal changes, but BSE remains an important tool for detecting significant changes, such as new lumps or changes in size, shape, or consistency. Women with fibrocystic breast tissue should be taught to perform BSE regularly and to report any unusual changes to their healthcare provider. Relying solely on BSE for breast cancer detection is not recommended, but it is an essential part of breast health awareness.

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Correct Answer is B

Explanation

A) Simultaneously palpating both arteries to compare amplitude: Palpating both carotid arteries simultaneously is contraindicated as it can obstruct blood flow to the brain, potentially causing a decrease in cerebral perfusion and leading to syncope or other complications. Each artery should be palpated one at a time to prevent this risk.

B) Auscultating the artery at the base of the neck at the carotid bifurcation: The correct technique for assessing for carotid artery blockage is to auscultate the artery at the carotid bifurcation, which is located at the base of the neck. The nurse should use the bell of the stethoscope to listen for bruits, which are abnormal sounds caused by turbulent blood flow due to narrowing or blockage of the artery. This is a non-invasive method used to detect vascular abnormalities.

C) Listening with the diaphragm of the stethoscope to assess for bruits: The diaphragm of the stethoscope is generally used for high-pitched sounds like lung and bowel sounds. For auscultating bruits, the bell of the stethoscope is preferred because it is more sensitive to low-pitched sounds, which are characteristic of bruits caused by turbulent blood flow in narrowed arteries.

D) Instructing the client to take deep breaths during auscultation: Instructing the client to take deep breaths is unnecessary and could alter the sound being auscultated. The nurse should have the client breathe normally to avoid interference with the auscultation of the carotid arteries. The goal is to listen for any abnormal sounds (bruits) without any external factors affecting the findings.

A. Tactile fremitus B. Adventitious sounds C. Friction rub D. Crepitus

Correct Answer is D

Explanation

A) Tactile fremitus:
Tactile fremitus refers to the vibrations felt on the chest wall when a patient speaks. It is assessed by placing the hands on the chest while the patient says "ninety-nine" or a similar phrase. Tactile fremitus is used to detect changes in lung density, such as consolidation or fluid. It does not describe a crackling sensation on the skin surface. A coarse, crackling sensation is more indicative of a different condition.

B) Adventitious sounds:
Adventitious sounds are abnormal lung sounds, such as crackles, wheezes, or rhonchi, heard during auscultation. These sounds are typically related to lung conditions, such as pneumonia, asthma, or fluid accumulation in the lungs. While adventitious sounds are significant findings during auscultation, they do not describe the physical sensation of crackling felt on the skin surface. Therefore, adventitious sounds are not the correct diagnosis for a tactile sensation over the chest.

C) Friction rub:
A friction rub is a harsh, grating sound heard during auscultation and is caused by inflammation of the pleura (the lining around the lungs). It occurs when the inflamed pleural surfaces rub together during breathing. While it is a distinct sound, a friction rub is not a tactile or palpable sensation. The crackling sensation described in the question is not related to the sounds produced by a pleural friction rub.

D) Crepitus:
Crepitus is the correct answer. It refers to a coarse, crackling sensation felt on the skin surface when air or gas is trapped under the skin, often due to conditions such as subcutaneous emphysema. This can occur when there is air leaking from the lungs or other parts of the respiratory system, often following trauma (e.g., rib fractures or surgery) or infection (e.g., gas gangrene). The crackling sensation felt during palpation of the chest wall is characteristic of crepitus, making this the most appropriate finding in this scenario.

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A nurse is conducting a class on Breast Self-Examination (BSE) for women of childbearing age. The nurse should include which of these statements that indicates the proper BSE technique?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing an assessment o a client suspected of having a carotid artery blockage. Which of the following techniques should the nurse to assess the client's carotid arteries?

Correct Answer is B

Explanation

A nurse is palpating a client's anterior chest wall and notices a course, crackling sensation over the skin surface. Which of the following should the nurse suspect from these findings?

Correct Answer is D

Explanation

A nurse is performing the diagnostic positions test. The nurse recognizes that normal findings from the diagnostic positions test should be which of these results?

A nurse is examining a client for tactile fremitus. The nurse should understand that what action is of primary importance when examining for tactile fremitus?

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A nurse is performing a voice test to assess a client's hearing. Which of these actions should the nurse perform?

The nurse is discussing Breast Self Examination (BSE) with a postmenopausal client. What instructions should the nurse give to the client about the correct time to perform BSE?